If you cannot email to us the above documents please do come in person and we will photocopy your documents and attach them to your file.

PLEASE ALLOW 3-4 WORKING DAYS TO PROCESS YOUR ONLINE REGISTRATION THEN BOOK AN APPOINTMENT IF YOU REQUIRE MEDICATION. IF YOU REQUIRE MEDICATION SOONER PLEASE SPEAK TO RECEPTION.

N.B Please be aware that if you are on highly addictive or controlled medications (i.e. tramadol, diazepam, temazepam etc) that we are unable to prescribe these medications until we have your old medical records, so please liaise with the reception to ensure we have these before booking an appointment. Please also note that we do not prescibe out of accordance with national and local medicines management guidelines.

*Please ensure you complete all the mandatory sections in order to be able to submit and process the application form.All the mandatory sections are starred *

Please note that if you are outside of the practice map area and are likely to require home visits i.e. housebound/mobility issues, then please register with a practice more local to you.

1Patient's Details*

Title*

First Name*

Surname*

Previous Name(s) i.e maiden name

Date of Birth*

Place of Birth (Town and Country)*

Current Home Address*

Post Code*

Home Telephone Number

Mobile Number*

Email addressBy giving us your email and mobile details you permit us to send you emails or texts relating to your clinical care (i.e. if you request us to send you a result).

Name of Next Of Kin (Emergency Contact in the UK)

Relationship to you i.e brother, son etc

Phone Number

2Please help us trace your previous medical records by providing the following information

Your previous address in the UK (please advise us here also if you have no previous UK address)

Name of previous doctor (NHS GP) while at that addressThis includes the name of the GP surgery/medical centre/health centre/medical practice

Address of previous GP

3If you are from abroad (please go to the section if this does not apply to you)

Your first address where you registered with a GP

If previously resident in the UK, the date of leaving

Date you first came to live in the UK (or approximate date if not known)Please ensure that you complete this section if you have come from abroad - otherwise we may not be able to process your application, especially if you have not been previously registered with an NHS GP

4If you are returning from the Armed Forces (please go to the section if this does not apply to you)

Address before enlisting

Service/Personnel Number

Enlisted date

5Background information

How would you describe your ethnic background? (this is not necessarily the same as nationality or country of birth)*

Are you a carer i.e. do you look after a friend or relative who is sick or disabled or has a significant mental problem or special needs (including a parent or guardian of a child)

Yes

No

Are you cared for by others? i.e. do you have a friend/relative who helps you live your day to day life

Yes

No

6About your health

Have you had ANY operations/surgery or suffered from other significant illnesses ? (if so please list below the details including dates)

Do you have ANY known ALLERGIES? (please include medication and non-medication i.e nuts etc)*

Please give details of all your known allergies below including the type of reaction (if known i.e rash or anaphylaxis)

Are you taking any medications? (this includes the contraceptive pill and occasional use medications as antihistamines/inhalers)*

If you are on any medication(s) please list their names and doses, frequency plus any other details

Smoking: Do you smoke?*

If 'yes', on average please indicate how many cigarettes a day do you smoke?

<10

10-19

20-30

>40

If 'No', have you ever smoked, if so how many did you smoke?

Alcohol: Do you drink alcohol*

If 'Yes', how many units on average do you drink per week?(NB 1U=1/2 Pint of Beer= 1 small glass of wine = 1 measure of spirits)

<5

5-9

10-20

21-30

30-50

>50

HIV:All new patients above the age of 16 are eligible to have a HIV blood test. If you would like this please request a blood test form from reception

Chlamydia: If you are sexually active you can do a self-taken Chlamydia test. These are available in the toilets of the surgery and can be handed in to reception.

7Family Health History

Have any close family members (parents, siblings, aunts, uncles and grandparents) suffered from any of the following illnesses

Heart Problems

Stroke

Diabetes

Asthma

Cancer

Other Hereditary Illnesses

If they do please give further details including who, what and the approximate age of onset?

8Females Only

Are you currently pregnant? If yes please when is your due date

Date of last Cervical Smear

Where was the smear taken?

Result Details (ie normal/abnormal and please also indicate if you have had previous abnormal and the details)

9NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply:

Any of my organs/tissues or

Kidneys

Heart

Liver

Cornea

Lungs

Pancreas

Any part of my body

At this stage we will be mainly noting your preferences internally. However, if contacted by the transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

PLEASE CONTACT THE SERVICE IF YOU WISH TO REGISTER by either visiting the website www.uktransplant.org.uk or calling 03001232323

10NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood

Yes (by ticking yes you are confirming consent to inclusion on the NHS blood donor register)

No

Tick here if you have given blood in the past 3 years

At this stage we will be mainly noting your preferences internally. However, if contacted by the blood & transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

PLEASE CONTACT THE SERVICE IF YOU WISH TO REGISTER by either visiting the website www.blood.co.uk or calling 03001232323

11FORM COMPLETION SIGNATURE

Signature of:

Please confirm the full name of the person completing this form (this will act as your signature and in doing you are also confirming that all the information provided is accurate)*

Date completed*

12Supplementary questions for all patients whom are not ordinarily resident in the UK (please go to the section if this does not apply to you)

Anybody in England can register with a GP practice & receive free medical care from the practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK. Some services such as diagnostic teats of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, rega

Please tick one of the following boxes

(A) I understand that I may need to pay for the NHS treatment outside of the GP practice

(B) I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge ("the Surcharge"), when accompanied by a valid visa. I can provide documents to support this when requested.

(C) I do not know my chargeable status

13Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS (please go to the section if this does not apply to you)

Do you have a non-UK EHIC or PRC

Yes

No

If yes, please enter details from your EHIC or PRC below

Country Code

Name

Given Names

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period (a) From

(b) To:

Please tick if you have an S1 (e.g. you are retiring to the UK or have been posted here by your employer for work or live in the UK but work in another EEA member state). Please give your S1 form to the practice staff

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purposes of recovering your NHS costs from your home country.

14Summary Care Record

You will be automatically opted in to the summary care record unless you tick the below box. This record provides basic information of allergies, medications & demographics details from the GP record to other hospitals for urgent care

15CIDR (Clinical Integrated Digital Record)

This is a local digital record which contains medical and social information similar to the Summary Care Record but in addition has useful information such as upcoming appointments, test results, conditions & diagnosis. This system is used both in hospitals and general practice to improve care patients receive. Having key medical information available in an emergency can save lives.We encourage all patients to allow creation of and access to this record. Should you wish to opt out please contact the surgery.Please tick here to consent for West Hampstead Medical Centre to access the record on your behalf.

16Thank you for taking the time to complete this form

17Patient online access

Please tick this box if you would like to be setup for online patient access that will allow you to book appointments and request repeat perscriptions

Please tick here if you would also like the facility to be able to see your results i.e. blood test results with comments requested by your GP

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form toWest Hampstead Medical Centre
•
9 Solent Road, London, NW6 1TP.

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please use one of the alternative methods offered by our organisation.